INQUEST calls for action as self-inflicted deaths, self-harm and violence in prison continues to rise

25 July 2019

The Ministry of Justice has today (25 July 2019) released the latest statistics on ‘Safety in Custody’, highlighting an increase in self-inflicted deaths and self-harm. This continues the historically high level of deaths in prison, seen in the past six years.

The key statistics on deaths in prison in the 12 months to June 2019 include:

86 self-inflicted deaths, up 6% from 81 in the previous year. This represents one self-inflicted death in prison every four days.

309 deaths in prison in total, only two fewer than the past 12 months despite increased investment and scrutiny.

165 deaths which the MOJ describe due to “natural causes”. INQUEST’s casework and monitoring show these deaths often reflect serious lapses in care (see notes).

55 deaths recorded as ‘other’ or awaiting classification, a particularly high number.

In the 12 months to March 2019, self-harm levels have increased by 24% from the previous year, once again reaching record highs. Self-harm incidents requiring hospital attendance have increased in male establishments by 4% and by 34% in female establishments. In the child and youth prison estate, there was a 30% increase in self-harm incidents. Overall, this reflects rising levels of distress in prisons.

Deborah Coles, Director of INQUEST said: "Every four days a person in prison takes their own life. Appalling inspection reports, damning inquest findings, and statistics on yet more deaths, have become so regular that those in power seem to forget these are human beings to whom the state owes a duty of care. Families continue to be traumatised, not only by the deaths, but by the failure to enact change.

Deaths, self-harm, violence, impoverished regimes and conditions are the daily reality of the prison system. Despair and distress are at unprecedented levels in failing institutions within a failing system. The failure to act on warnings from inspection, monitoring, investigation bodies and inquests exposes an accountability vacuum allowing dangerous practices to continue.

The new Justice Secretary must act upon what are clear solutions - tackle sentencing policy, reduce the prison population and redirect resources to community health and welfare services. This however requires bold and decisive action at a political and institutional level, not more empty words.”

Levels of assaults in prison have also risen, reaching record highs. This comes despite programmes of investment focused on reducing violence and increasing security over the period in the 10 most ‘challenging’ prisons. In the 10 prisons themselves, the total number of deaths has risen.

Analysis of INQUEST’s casework shows that recent inquests on deaths in prison highlight repeated and systemic failings around self-harm and suicide risk management (known as ACCT procedures), drug prescribing processes, communication, record keeping, inadequate healthcare, and procedural failures and delays. See relevant inquests in the notes.

The Office for National Statistics has also published experimental statistics looking at the risk of suicide and drug-related deaths for men in prison compared to the general male population. They found, the risk of male prisoners dying by suicide was 3.7 times higher than the general male population during the 9-year period they considered.

Inquest concludes a series of failings contributed to death of Shane Stroughton in HMP Nottingham. Media Release, June 2019.Shane Stroughton, 29, died a self-inflicted death on 13 September 2017. The jury unanimously agreed that there was inadequate mental health care, a lack of trained ACCT assessors and a failure of prison staff to communicate with Shane’s family regarding incidents involving him at HMP Nottingham.

Critical inquest finds systemic failures and missed opportunities contributed to death of Tyrone Givans at HMP Pentonville. (Media Release, January 2019).Tyrone Givans, 32, died a self-inflicted death on 26 February 2018. The jury found that the following factors contributed to Tyrone’s death: Tyrone’s alcoholism, substance abuse and profound deafness were insufficiently processed and addressed, staff communication was unsatisfactory, prison record IT systems were unfit for purpose and the inadequate recording of prison patient records.

Jury returns damning conclusion at inquest of Andrew Brown at HMP Nottingham. Media Release, June 2019.Andrew Brown, 42, died a self-inflicted death on 17 September 2017. The inquest concluded that there were numerous failings which contributed to his death, including a failure to follow procedures, an unsuitable environment which did not meet his basic needs, failure to respond to the emergency bell and a failure to investigate an earlier assault on Andrew.

‘Natural cause’ deaths in prison

Parliament’s Health and Social Care Committee inquiry on healthcare in prisons concluded in November 2018, agreeing with the evidence of INQUEST that ‘so-called natural cause deaths too often reflect serious lapses in care’. See recent inquest conclusions:

Teenager whose meningitis and heart condition was overlooked was failed by HMP Doncaster healthcare staff, inquest finds. Media Release, July 2019.Jordan Hullock, 19, died on 30 June 2015. The inquest jury concluded Jordan’s death was by natural causes, and that there were serious failures and shortcomings in his care in the days leading up to his death.

Inquest finds serious failures at Sodexo run HMP Peterborough contributed to death of Annabella Landsberg. Media Release, April 2019.Annabella Landsberg, 45, died from complications relating to her Type 2 diabetes on 6 September 2017. The inquest jury found failings on the part of the prison, healthcare staff, GPs and custody officers contributed to the death of Annabella Landsberg.

Neglect and serious medical failures in Sodexo run prison contributed to death of Natasha Chin. Media Release, December 2018.Natasha Chin, 39, died less than 36 hours after entering Sodexo run HMP Bronzefield on 19 July 2016. The inquest jury concluded her death was caused by healthcare failures and contributed to by neglect.

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